Own place runners registration form

Fields marked with an '*' are mandatory.

Name of event you are taking part in: *

Title: Mr Mrs Miss Ms Prof Dr Lord Lady Sir

First name: *

Surname: *

Date of birth (date/month/year) e.g. 16/03/1977:

Email: *

I would like to be kept up to date with RNIB news and activities.

Daytime phone number:

Evening phone number:

Mobile:

Address line 1: *

Address line 2:

Address line 3:

Town/City:

County:

Postcode: *

Occupation:

How did you hear about Team RNIB events? Choose one Advert (please specify publication below) Email from RNIB Facebook Family or friend RealBuzz RNIB website Search engine (e.g. Google) Taken part in an event before for RNIB Word of mouth Other (Please state)

Other (please specify):

Publication you saw advert in (if relevant):

Size of RNIB t-shirt you would like: Choose one Small Medium Large Extra large

Amount in GB pounds you pledge to raise for RNIB:

I pledge the amount specified above.

Comments: